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U1SW1__b?,GROU_VD STORAGE TANK SPSTEM UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS For use by Unidocs Member Agencies or where approved by your Local Jurisdiction Authority Cited: Title 23, Div. 3, Ch. 16 California Code of Regulations (CCR) FACILITY NAM.E.. FACILITY PHONE FACILITY SITE AD SS CITY REASON FOR SUBMITTING T IS FORM (Check One): Z Change of Designated Operator ❑ Update of ICC Certification Expiration Date(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME: ECIC Wayne Garcia RELATION TO UST FACILITY (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician N Third -Party BUSINESS NAME Vfdifferentfromabove): GDF Solutions, Inc. DESIGNATED OPERATOR PHONE: (925) 292-0821 ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5094004_UC EXPIRATION DATE: 11/27/2W,1,olo ALTERNATE i DESIGNATED UST OPERATOR FOR THIS FACILITY(Ontionat) DESIGNATED OPERATOR NAME: Ian Hall RELATION TO UST FACILITY (Check One) ❑ Owner Operator ❑Employee ❑ Service Technician ® Third -Party BUSINESS NAME Qfdifferentfrom above): GDF Solutions, lh .-- DESIGNATED OPERATOR PHONE: (925) 292-0821 ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5311539 -UC EXPIRATION DATE: 3/6/2010 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY Wvdonal) DESIGNATED OPERATOR NAME: Ralph Thomas RELATION TO UST FACILITY (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician N Third -Party BUSINESS NAME Vf differentfrom above): GDF Solutions, Inc. DESIGNATED OPERATOR PHONE: (925) 292-0821 ext. INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8001428 -UC EXPIRATION DATE: 0111012010 ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY (opi mi) DESIGNATED OPERATOR NAME: - aftli, RELATION TO UST FACILITY (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician N Third -Party BUSINESS NAME (Ifdifjerentfromabove):}(g44133 Inc. DESIGNATED OPERATOR PHONE: (9.?1k_ z1 ext INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DA',:.�� I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST Operator(s). The individual(s) will conduct and document monthly facility inspections and annual facility employee training in accordance with California Code of Regulations, Title 23, Section 2715(c) through (f). Furthermore, I understand and am in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks. TANK OWNER NAME: —CA_r4..G L 'WANK OWNER TITLE: � � OWNER PHONE: (" ) TANK OWNER SIGNATURE: DATE: Z INSTRUCTIONS 1. Report the name(s) of the Designated UST Operator(s) as registered with the International Code Council (ICC). ICC certification information is available on-line at: www.iccsafe.org/e/r-ertsearch.html. Search for "California UST System Operators." 2. Submit this completed form to the local agency that regulates this facility's USTs. Unidocs member agency jurisdictions and contact information are listed on-line at: www.unidocs.org/members/whoregulateswhat.htnd. Contact information for other local agencies within California is available at: www.swrcb.ca.goy/cwphome/usttcontacts/docstiocal_agency_list.xb. 3. 23 CCR §2715(x) requires that you notify the local agency of any changes to this information within 30 days of the date of change. UN -062 - 1/1 www.unidocsorg 09/22/05